Michael Fine 5282 words

348 Gleaner Chapel Road

Scituate, Rhode Island 02857
401.617.4780
M1fine@aol.com

THE FAILURE OF FAMILY MEDICINE

By

Michael Fine

3/17/2016

New to Establish. Chief complaint: tired and hunger pains x 3 days.

History of Present Illness: 36 year old English speaking Latino female with fatigue and

abdominal pain of three days duration. The fatigue is so severe that the patient wasnt able to get

out of bed two days in a row very unusual for her and her two girls, ages five and seven, had

to wake her in the morning so they could get to school on time. Usually its the other way

around. The patient works in an office as a receptionist and never misses work but she did have

to work an eleven hour day on Monday which was okay for her she likes the overtime and her

girls go to her mother in Pawtucket after work. The abdominal pain actually started last June and

keeps her up at night. Its burning and boring, comes and goes, but when it comes on its there

for weeks at a time and is associated with burping and belching. Worse when she lays down,

better when she stands or walks, the same feeling she gets when she is hungry only ten times
 The Failure of Family Medicine, Michael Fine, 2

worse. No nausea, vomiting, or diarrhea. No blood in the stool or black tarry stools. No fever or

chills. Not emotionally stressed. She lives with her two daughters who she says are her whole

world. Sleeps ok except for the discomfort. Poor appetite. No meds. Doesnt smoke. Drinks

occasionally. Needs a note for work states her boss is a good person but very precise and says

she needs a doctors note if shed out more than a day or two, but she likes her boss who she says

is fair but strict. The patient was seen at an urgent care center two weeks prior for the same

abdominal pain but without the fatigue when the pain was keeping her up at night. They ordered

an ultrasound which she is going to have tomorrow. Her boss knows about that already and

understands she will be in late so the out of work note she needs is only for yesterday and today.

Review of Systems: No trouble swallowing. No cough or wheezing. No chest pain or pressure.

Exercises regularly. Regular periods but very heavy flow. No back pain or muscle pain. Nerves

and emotions ok. Mood good, but worries about her daughters from time to time. Doesnt see or

hear things that might not be there. No thoughts of hurting herself or anyone else. Had diabetes

with her pregnancies that resolved after her children were born.

Physical examination: is remarkable only for epigastric tenderness. No masses spasm or rebound.

No Murphys sign. Normal bowel sounds.

Laboratory studies: blood sugar 146 (elevated but she just ate). Hemoglobin A1c 6.1.

Assessment and Plan:

#Fatigue and hunger pains. Likely recurrent diabetes. Will refer to

nutrition for diabetic diet and teaching. Start metformin 500 mg twice a

day. Consider and test for Lyme disease (fatigue), anemia from blood loss

(heavy periods), gall bladder inflammation (fat forty and fecund).

 The Failure of Family Medicine, Michael Fine, 3

#Abdominal pain. Possible gall bladder. For sonogram elsewhere. Will ask

patient to have the radiologist send us the results.

Recheck 3 months.

When I met Julio it felt like the world had flipped over, turned itself inside out and

righted itself again. After I threw the girls father out, that two timing son of a bitch, I thought I

was done with men and that my girls would be enough for me forever. Sure I went out on Friday

nights. You have to get dressed and go out, put makeup on, drink a little and dance a little once

in a while otherwise you dont feel like you are alive. My mother would come over to be with the

girls. Mostly it was girl talk and girls dancing with each other. The men would come sniffing

around, pretty ghetto, lots of bling and baseball hats, thinking themselves so hot but there was

nothing there, no one to take seriously.

But Julio, now that was a whole different kind of man, serious, smart and adult, dark and

quiet and really good looking, like one of those men in the newspaper who model mens suits.

We were both at a wedding when we met -- the wedding of my bosss daughter Ashleigh, who

was marrying a guy from Boston who she met after college when they were both working in

New York, both very smart and successful people. I didnt think there were going to be any

Spanish people at the wedding, which was at a very pretty place in Bristol overlooking the ocean.
 The Failure of Family Medicine, Michael Fine, 4

Me and the other girls from the office, we were at on our best behavior, and I was thinking,

pretty night, pretty bride, the girls and I would sit together and talk and then wed dance like we

do at the office Christmas party when only the girls dance and the men, they just sit there and

drink beer.

You sometimes dont really see the person who sits next to you at a table because you

have to turn to look and I was talking to the girls when Julio came to the table. He was alone and

went from person to person, going around the table, introducing himself and saying, Julio

Mendez, party of the groom. Julio Mendez, party of the groom. Julio Mendez, party of the

groom. Very formal and polite, like he was the principal of a school or the captain of a ship.

Dark suit, dark, thinning hair, dark smart eyes that kept to themselves, but he looked at you, just

for a moment, and his eyes didnt go right from your face to your chest, the way half the men in

the world do. Big shoulders but not tall, maybe a little taller than me but not much and a strong

grip when he shook your hand, strong and warm like he was learning you with his grip and really

wanted to know what made you tick from the way you squeezed his hand.

And he was wearing a pink almost purple silk tie that stood out, that was different from

how the rest of him looked. That said, there is something different about this man, something

alive inside courage and pride and passion so that how he looks and acts might not be all of

who he is. Anyway he sits down next to me and I dont look at him and he sits there, quiet for a

few minutes. He knows Im Spanish and I know hes Spanish but neither of us are saying

anything and Im waiting for him to turn to me or for me to turn to him and for one of us to make

a little joke in Spanish about being Spanish at a place where there werent any others, about

waiters or something, the kind of thing Spanish people say to ourselves about each other when

no one else is looking but he doesnt do that at all. He turns to me and says, Id like to know you
 The Failure of Family Medicine, Michael Fine, 5

better. Tell me about your life, which is not what you expect to hear from a man you are sitting

next to at a table at a wedding and he says it in English, that beautiful clear formal English he

speaks, as if hes Castilian and is speaking English Castilian and I talk to him in English and I

tell him about my life and my girls and hes listening, asking questions, and he really gets me,

like he knows something about what I had to live through with the girls father, like there are

things hes had to live through himself but he doesnt talk about those things. Im liking the

strength in this man who has feelings and a good brain, who has a heart but doesnt wear his

heart on his sleeve. Thats what strength is. We talk English to each other always. Except later,

when we talk Spanish to each other in bed.

5/1/2016 Same day acute 36 year old Hispanic female with abdominal pain and trouble

sleeping. Still uncomfortable and did not want to wait for scheduled follow-up Lots of burning

in the chest which keeps her up at night. The chest pain is midline, not on the left. Does not

travel to the left arm or shoulder. Worse when she lies down. Not worse with walking or

climbing stairs and walks four to six blocks a day to the bus which she uses to travel to work

but no regular exercise program. Not short of breath with walking. Work is busy but not

stressful. Does not eat a low cholesterol or limited calorie diet. Drinks two to three cups of coffee

a day and a glass of wine or two each night to relax after her children are in bed. Not a smoker.

Pain is still like a hunger pain. Did not take the metformin.

Examination: reveals no chest tenderness, no pleural or pericardial rub, normal heart sounds with

no murmur, good breath sounds equal on both sides. Abdomen soft not tender without rebound
 The Failure of Family Medicine, Michael Fine, 6

or spasm and normal bowel sounds. Extremities without swelling or edema. Patient appears

anxious.

Laboratory studies: Lyme negative. Hemoglobin 12. Low normal. Hemoglobin A1c 6.0 today.

Ultrasound elsewhere reported by patient to be normal.

Assessment and plan:

#Chest pain. Rule out heart disease. Check cholesterol and stress echo.

Might consider reflux gastritis if normal.

#Diabetes controlled by diet and exercise. Ok to wait on metformin.

Reinforced nutrition consult which is booked for two months hence

diabetes teaching has a big backlog.

Return to clinic one month, after stress test done. To call for more chest pain. To call 911 and go

to the Emergency Room for chest pain that lasts more than three minutes, that feels like someone

is standing on your chest or that you feel in the left arm or shoulder.
 The Failure of Family Medicine, Michael Fine, 7

I thought Julio would call me but he didnt call me and for a while I forget about him.

You know how it is. You meet someone and I dont know, they make you pay attention in a

different sort of way and you think, maybe, cool, maybe more, and then they dont call you and

the girls need this and that and then you forget about that person you met.

So a few weeks later I see my cousin Yvette at La Consona and she says I heard you met

my husbands brother Julio and that he thought you were very hot, and I say, who, and then I

remember and I guess I start to turn colors or something so she pushes me a little, kind of like a

love tap, and she says, oh, oh I see the way it is and I say its not anything. I met the guy and

never hear another word from him so what good is that, and she says, hes a very good man and

hes been through a lot and she gives me the lowdown: he has a wife and three kids but the wife

is more than a little crazy, in and out of the loony-bin, so he takes care of the kids who are now

teenagers and he takes care of the wife when she is good enough to be home but that he is mostly

alone. So he doesnt call me because he cant call me.

And then its the summer and Yvette calls up and says bring the girls to the Columbian

Festival which is Sunday so I bring the girls and my mother and we are standing in the middle of

that field looking at the exhibits and so forth and listening to a band that is playing Columbian

music but way too loud and then it starts to rain. The girls are running around somewhere so I

find them and go to the big T-Mobile tent to get out of the rain and Im standing there with the

girls and a man comes in, hes holding a program book over his head to keep the rain off and its

Julio. Hey I say. Hey, he says. And then I introduce the girls and my mother.
 The Failure of Family Medicine, Michael Fine, 8

6/1/2016 Follow up: 36 year old Hispanic female with abdominal pain and trouble sleeping.

Much more burping and belching. Pain still present, worse at night. Radiates to left shoulder.

Not present with walking or climbing stairs. Nausea, no vomiting. Anxious but no real feelings

of impending dread when the pain is present. Pain lasts for hours. No shortness of breath.

Everything at home and work ok. Had the sonogram negative by patients report report not

in the chart, but the stress echo is still pending, was rescheduled by patient. Hemoglobin A1c 5.8

today. No diabetic teaching yet. Did not start Metformin. Watching calories and walking

everyday (to the bus).

Exam: clear lungs. Heart regular rate and rhythm. Abdomen soft not tender no Murphys sign ?

epigastic tenderness. Extremities without edema

Assessment and Plan: # Rule out heart disease. Needs to be careful with exertion until

stress echo done is walking to the bus, but call 911 for crushing

chest pain.

# Diabetes. Controlled by diet and exercise. Watching calories and

exercising.

Soon Julio starts to come around. Hes shy about it. Very proper. I have a question about

my kids, he says. Could I buy you lunch and pick your brain, he says on the phone. I only get

half hour for lunch, I say. Okay how about dinner. The girls are with my mother after school and
 The Failure of Family Medicine, Michael Fine, 9

she spoils them. I make them wash the dishes and do their homework. They are thrilled to stay

with abuela one day she lets them watch TV and eat junk food. His kids are 18, 17, and 15. He

doesnt want them sitting on the computer all night or watching TV but thats all they do, watch

TV on the computer in their room. They need the computer for homework. Is he wrong? Just old

fashioned? No I say, they need to sleep and they need to read. Make a rule. No computer after

nine PM. And then turn the router off every night at nine. Theyll watch on their smart-phones,

he says. Take their smart-phones every night at nine. Given them back at breakfast. That way

theyll eat breakfast. They need to talk to their friends, he says. Its after nine. They need to

sleep, I say. But they say its not cool, he says. You have a landline? I say. If they need to talk,

let them use the landline. You can watch that. They yell that makes them not cool, he says. They

say that makes them different. You are the father, I say. You love them and want them to

succeed. There is plenty of time for them to be cool when they are twenty-two and on their own.

Enough kids go ghetto already. You are smart he says. Way smarter than me.

He never says a word about the mother of these kids. He drops me at my house, thanks

me, and shakes my hand, like we are in a business meeting or something. Then he calls the next

week. Every week there is something for advice. About his mother, who is living in Baltimore.

About his business. He owns a little company that makes electrical things, circuit boards and

switches, that he started fifteen years ago in his basement because he has a good head for math

and a good head for engineering which is what he went to college for in Columbia, and he has

twenty-seven employees who always fight with each other, with endless drama. All of a sudden

I am an expert at kids, at families, at labor relations, and he needs my advice. Some weeks I

dont hear from him, and Im guessing then his wife is home or acting up. Julio never complains.
 The Failure of Family Medicine, Michael Fine, 10

But one day at dinner I say tell me how your wife is this week, and his eyes get dark and

he starts with a whisper so he goes back and starts to speak normally after the first few words,

when he hears himself talking like that. Shes stable, he says. Shes home and everything is

under control, he says. That night his handshake turns into an embrace. I kiss him on the cheek

and he holds me to him, hard and close, as if he is holding on for dear life.

7.12/2016 Follow-up Did not keep appointment.

We go to Slater Park on Sundays. We do the Carousel, which the girls love, but mostly

we sit in the park and the girls run free. They do the playground and they run down to the lake

pretending to be this and that, and sometimes they meet other kids in the playground and they

create a whole little telenovela that unfolds on the banks of the lake and has them running in and

out of the trees and hiding behind the kiosks and the out buildings, while Julio and I sit in the

sunlight and talk.

He is an attentive man, that Julio, but tense. One day as we go to leave and he is

standing. I see him stop and fall back and then try to stop and stand again and then stop again, his

face set and serious, and then he struggles slowly to his knees and from his knees to his feet.

What is it? I say. Its nothing he says. Just my back. A little pain. A little spasm. I can fix the
 The Failure of Family Medicine, Michael Fine, 11

back, I say, laughing, because it is beautiful out and he is a beautiful man and I feel like I can fix

anything and everything and that life it is so good. And when he stands I come behind him and

put my hands on his shoulders and start to give him just a small massage. The muscles in his

shoulders and neck are big and stronger than I ever imagined and they are tight like the steel

cables that hold bridges up, and they do not loosen much when I knead them as if they were

dough because they resist the pressure of my fingers, but Julio says, bueno, which is the first

Spanish word he ever says to me, and then he turns quickly away from me, as if I have hurt him

or he is frightened and his face is very dark. It is good, I say. It is okay. Come to my house later

after 930 when the girls are in bed. It is okay Julio. I cannot go to your house, he says. It is not

proper. It is okay, I say. And he turns and walks stiffly away. I can see how stiff he walks, how

he feels each step in his back and neck which are in spasm.

That night he comes to my house after 930 after the girls are in bed and he stays only

until midnight. Later I learn that he is parking his car around the corner and down the block so no

one can tell, but then he comes to my house many nights between nine-thirty and midnight, and I

give him a key, and sometimes he comes between 4 am and 6 am so hes gone when the girls get

up, and nobody knows and everybody knows at once, and I am loving him and I am not

ashamed.

9/20/2016 Open access/ Same Day Acute 36 year old Hispanic female with abdominal pain

and trouble sleeping. DNKA last visit because she was feeling better. Now pain and trouble

sleeping back again. Had stress-echo which was normal. Still has chest pain and abdominal pain
 The Failure of Family Medicine, Michael Fine, 12

suddenly worse at night, keeping her from sleeping. Sleeping less only a few hours a night

now. Not exercising. Drives to work. No new stresses. Family status unchanged. Single mother

of two young daughters. Doesnt smoke or drink. Not concerned about her personal safety

because of any relationship issues no intrapartner violence. No change in diet eats fruits and

vegetables some but not too much citrus or other acidy foods. Has been drinking milk and

taking Tums at night and that helps her to sleep.

Examination: Mucus membranes pink. Clear lungs. Cardiac regular rate and rhythm. Abdomen

soft with moderate epigastric tenderness replicates pain! No mass or other tenderness no

rebound. Extremities not tender without edema.

Assessment and plan: #Reflux gastritis, rule out H Pylori. Check H Pylori titers. Start

Prilosec 20mg daily for 30 days . Recheck one month.

And then Julios wife improves.

Suddenly Julios wife is awake and alert and making dinner. Cleaning the house. Paying

the bills like she used to do, once upon a time. Asking about his day. Maybe it is the medicine.

Maybe it is her brain was injured and has healed. Maybe it is an act of God. I wonder if it isnt

me, if they arent bad for each other, and when Julio is with me she has the space again to live.

Maybe she knows about me, and makes herself recover to get him back, as if her illness wasnt

always just the way she talked to him, the way for her to get his attention away from his kids and
 The Failure of Family Medicine, Michael Fine, 13

his work. It doesnt matter. She is better. She is awake and alert and she knows that something is

going on. That I am going on. I know that Julio never thought this was possible. That he came to

me in sadness and loneliness, mourning his wife, his family and his marriage, but now he is torn

in two. I know he loves me and that he respects his wife but he doesnt love her. I know that that

he now likes his wife again but he doesnt love her. I know he loves me, that he loves my girls

and everything that is false about the world becomes true for him when he talks to me, when I lie

in his arms.

I stop sleeping. He comes now once a week and doesnt stay long. He looks dark, the way

he looked when we met.

I am glad for him. I am glad for his wife. I hate him. I hate his wife. My girls are sad.

They think about him, and they are sad. They think about me, and they are sad. His children

brighten, and do better in school.

I am not sleeping. There is an ache in my chest where my heart should be. An ache, not a

pain. There is a burning. I am sitting up all night. A part of me is always listening for his key in

the door. He is a good man, an honest man, a man of principals and tremendous integrity.

It was not like this with the father of the girls. The father of the girls, he just used me,

flattered me, and tricked me. I was nothing to him and when the time came I threw him out

because I always knew he was no good. This is different. I love Julio.

So I end it.

Then it feels like I will never sleep again.

 The Failure of Family Medicine, Michael Fine, 14

10/20/2016 Follow-up H. Pylori gastritis. 36 year old Hispanic female with abdominal pain and

trouble sleeping. Some improvement with Prilosec but still not sleeping. Burping and gas much

less. Burning and chest pain less. Some nausea, no vomiting or diarrhea. No appetite. Not

bloated. Hunger pain gone but still left with an empty feeling. Mood down. Sad but not hopeless.

Not sexually active. No suicidal or homicidal ideation. Doesnt like the short days or the winter.

Examination: Lungs clear. Heart regular rate and rhythm. Abdomen soft, not tender, normal

bowel sounds no mass. Extremities without edema.

Laboratory: H. pylori was positive

Assessment/Plan: #HPylori Gastritis. Add Lansoprazole 30mg twice daily for 14 days.

Amoxicillin 500mg twice daily for 14 days and Clarithromicin 500mg

twice daily for 2 weeks. Possible side effects diarrhea and a metallic

taste in the mouth. The importance of taking all the medicine reviewed in

detail.

#Depression versus Seasonal Affective Disorder. Trial of bright light 30

minutes twice times a day for one month. Recheck then. If no

improvement consider behavioral health referral.

Recheck 4 to 6 weeks.
 The Failure of Family Medicine, Michael Fine, 15

At 4:30 in the morning I think I hear a key in the lock. I have not forgotten Julio but I

have put him out of my mind. Ancient history. Sadness. Dont go there. You live and you learn. I

am thinking about the girls father who I havent seen or heard from in two years but who still

has a key and it is like him to come sneaking around when hes in trouble or when his girl of the

moment has thrown him about. Sneaking around or worse. He has done me worse. I thought

once to buy a gun so I would be ready for him when he comes around again but I dont have the

stomach for that and I dont want it in the house for the girls to see or the girls to find. But I do

have a baseball bat. A metal bat from softball. Once when I was a girl I played. Then the noise

goes away. I open the door. There are flowers between the front door and the storm door. From

Julio. Its four-thirty in the morning. I am looking for him but all I see are the red tail lights of a

car driving away. Julio is gone. He was here. And he is gone again.

12/1/2016 Follow-up 36 year old Hispanic female with abdominal pain and trouble sleeping.

Abdominal pain resolved. No burping. No belching. No bloating. Mood improved. Not sleeping

well though. Often wakes at 4 A.M. but then able to go back to sleep so often gets 7 hours a

sleep a night in total. Using a light with daylight spectrum an hour or two a day as instructed.

Appetite fair. Not stressed. No suicidal or homicidal ideation. Not seeing or hearing things that

arent there. No chest pain.

Examination: Lungs clear. Heart regular rate and rhythm. Abdomen soft without masses. No

Murphys sign or rebound. Extremities without swelling or edema.

Assessment and Plan:

 The Failure of Family Medicine, Michael Fine, 16

# Reflux gastritis. Resolved.

#Seasonal Affective Disorder. Effectively treated with light

therapy.

#Sleep Disorder early awakening. Sleep hygiene reviewed. On

awakening patient is to get out of bed and read for at least twenty

minutes or until she feels sleepy and then return to bed. No TV in

bed. Use bed only for sleep or sex.

Return to clinic in 3 to 4 months for regular health maintenance

examination. Will recheck hemoglobin then and consider iron for

heavy periods.

We work it out. It is hard but we stay with it. One day I call him up at his place during the

day. Stop bringing flowers, I say. I love the flowers but it isnt flowers I want. I cant sleep Julio.

I want you back but all of you not just flowers in the middle of the night. I am sorry, he says. I

thought you would be pleased. I still think about you. All the time. Thinking about me doesnt do

anybody any good, I say. Its very nice that you like me. Its even very nice that you love me.

But loving and liking arent the same thing as two people being together. I need someone for me,

or no one. And I need someone for my girls.

 The Failure of Family Medicine, Michael Fine, 17

Then I dont hear from him for two weeks. I gave my word, he says, when he calls me.

This is not your problem it is my problem. I promised I would take care of her in sickness and in

health. She is better now and that is good. But what is inside me isnt better. I dont care

anymore what is inside you, I say. You are ripping me to pieces. Love me or let me alone.

He knocks on the door one night after the girls are in bed. He is looking dark like he is

angry at me.

Im going to stay married to her, he says. Why are you here, I say. You are making it

worse for me, not better. I am going to stay married to her but I want to live here with you. Nice,

I say, very nice. You get your cake and eat it. What about my girls? Dont you think they need a

real father? And what about your kids? They need a father too. I thought youd be happy to see

me, he said. Maybe I shouldnt have come. Shit or get off the pot, I say. I do love you but you

are tearing me apart. What I came to say is that I am going to stay married to her but we will

make this work. I found a clean three family on Transit Street. A beautiful old house. Four

bedrooms in the upstairs apartment. Three bedrooms in the downstairs. It has a big yard and a

carriage house. And you want us all to live together? Are you crazy? You want me to live in a

triple-decker? I say. How very convenient. What about your wife? Its not a triple-decker, he

says. Its a real house. My wife knows all about you, he says. You were her shock therapy. She

got better. But we didnt. She and I didnt get better. She knows it is you and me now. And it

sucks, but this is the best I can do. Maybe someday she finds someone else and we divorce. But

not now. Now I am with the kids and I am with you and we find a way to make a family out of

the terrible mess I have made. You didnt make a mess, I say. You got a mess. Now you are
 The Failure of Family Medicine, Michael Fine, 18

trying to make lemonade out of lemons. But I dont know if I can do this, I say. I dont expect

you to, he says. Its too crazy. I dont know what I will say to his wife, who I only feel sorry for.

I dont know what I will say to his kids or how they will look at me. How they will think about

me. I dont know how his wife will be able to stand it. I dont know how I can stand it. Maybe it

will make her crazy again. Or me. Or both of us together.

No. That is not right, I say. Shit or get off the pot. You want to be with me? You divorce

her and be with me. Or nothing. No discussion. No options.

But then I feel like I know his kids from all he has told me about them. He is twisting

himself in knots for me. For my kids. For his kids. For us. But no. This is crazy.

Julio is a good man. The best. But now I am strong for two of us. I look into his eyes

where he is waiting for me, lost and alone. I cannot turn him away but I cannot do this thing. I

take his face in my hands and I kiss him. I stand behind him and knead the terrible knots in his

back. He turns to me. We will sleep together one more night.

And then never again.

In the morning I change the locks.

6/1/2017 First Prenatal visit. 37 Year old Hispanic Female. Last Menstrual Period 4/12/2017.

Positive pregnancy test. Risk Factors: Advanced maternal age. Iron deficiency Anemia. History

of Depression. Adult onset Diabetes Mellitus, diet controlled. Estimated Date of Delivery

1/16/2018. Father of baby not involved.